Transcription of the episode “Transitions to adulthood: Supporting teens with mental health issues”

[00:00:15] Jon M: Hi. I’m Jon Moscow. Welcome to Ethical Schools. My cohost, Amy Halpern-Laff, will be back next week. My guests today are Marsha Ellison and Evelyn Frankford. Dr. Ellison is an associate professor of psychiatry at the University of Massachusetts Medical School and director of communications at the Transitions to Adulthood Center for Research. Evelyn Frankford of Frankford Consulting is a consultant with decades of experience in New York and Massachusetts working on issues affecting transition age youth. We will be discussing issues affecting students with serious mental health conditions. Welcome Marsha and Evelyn.

[00:00:48] Evelyn F: Thank you, Jon. It’s a pleasure to be here.

 Thanks for the invitation.

[00:00:52] Jon M: How many children and young people in schools are estimated to have serious mental health conditions? 

[00:01:00] Marsha E: Well, it depends on how closely you define, you know, serious mental health conditions. I think the estimates can go up to 30% or so, and only a small portion of those youth will be identified for special education among all the youth who might have mild anxiety disorders all the way through youth who are identified with significant mood disorders. 11% of them seem to wind up in special education, and the rest of them are struggling through school. And we will find that by the time they get to high school, there’s very significant dropout rates among those who are not in special education in particular, but have those serious mental health conditions. As many as 50% of those youth who are identified as having that kind of mental health condition will drop out of high school. So they are a population of very significant concern for educators and policy makers.

And even those not in the education system, looking at the CHIP data, which I was just looking for Child Health Insurance Program and Medicaid. Of Medicaid enrolled children, a third have a mental health disorder, but not very many get served. And most of those get served through a clinic, an outpatient clinic, which often is not necessarily the right remedy or the right intervention for the kind of difficulty the child has.

[00:02:45] Jon M: So that actually leads me to the question of how well equipped are most schools to recognize and serve children and youth with serious mental health issues, and what characterizes schools that are able to do a better job than others?

[00:03:04] Marsha E: Well, what tends to happen is that students who have a clear behavioral disorder are the ones who are identified first. Obviously, you know, teachers are trying to run a classroom. And if there is, there are interfering behaviors, that’ll be the child who is identified and we’ll go through an eligibility, determination process for special education. There are many students who are suffering quietly in the back and don’t show up to class and similarly have a mental health condition who don’t get identified.

They may wind up getting sent to nurses or guidance counselors in the schools and in my experience, the nurses and the guidance counselors have a pretty good idea of who might have a mental health condition in their classroom, in their school, that are otherwise not being served in special education. And these folks, sadly, are aware, but not trained to deliver mental health services. They may work with families to try to encourage them to get external mental health help, but they’re not mental health clinicians. So it really becomes a population in need and unserved. 

In the decades since things like three tiered approach has been introduced, MTSS, multi-tiered system of supports, which has a very positive development with the idea that there are three tiers: prevention for all students, early intervention for some students who show some difficulties, and the third tier would be access to more intensive services for the students we’re probably talking about. This is a wonderful thing, but it also is generally overstretched. And on Tier Three, there’s still a limit. It’s hard to find the kinds of interventions that could really make a difference. 

So schools have done this. And some of the work has looked at what are the community influences. That has always been a challenge to try to understand how a student is coming to school with influences from the outside world and what that means for the student’s performance in school.

[00:05:34] Jon M: So you’re saying even when students are referred to special education classes or services, there may still be real limits in how adequate or effective these services are. Is that right? 

[00:05:51] Evelyn F: I’m not an expert on all schools and what they do. I know the work I did on one project, you know, where we were talking about the three tiered system of supports, we were identifying how difficult it was to get the range of interventions. And I think even when we talk with one school district in Westchester that I’ve been working with in the last year, the question of what is the actual intervention? It’s still hard to identify even if the child is in special ed. So if it was a three tiered system of support, because many of these young people don’t want counseling. They really have said we’ve been in services all our lives, we don’t want to be counseled. And the kind of intervention that works tends to be very focused on helping them function in the world. And that’s very labor intensive. 

[00:06:47] Marsha E: Yeah, I’m familiar with one third tier intervention called Renew that came out of the University of New Hampshire. It’s really a transition focused service, but it’s meant to serve, you know, these students who really require intensive support in order to stay in school. 

And you know, it’s not counseling and it’s not mental health. That is kind of the challenge for our field, really, is to provide supports that differ from the medical model, and really address their functional needs, their actual dreams and aspirations and work with their natural motivations that way. And their natural motivations are not, I want to go see a therapist once a week one, and I don’t want my mother to drag me to the psychiatrist so that I can get more medication. That typically doesn’t work, especially when we have data that shows that as youth mature and are able to become more independent from their parents, that the rates of dropping therapy and medications, that they just plummet.

And so then you wind up with mental health crises a little bit later in life. So a lot of our work is really trying to respond to the functional needs and having students succeed in school and succeed as they get older in employment and post-secondary goals. And in that way, build emotional supports and social capital and human capital that will carry them through into adulthood.

[00:08:25] Evelyn F: The thinking that has evolved in the last 20 years to researchers, including at the U Mass Center, Transition Center and others, is that positive youth development, building a relationship with, the one-on-one relationship, with this young person around their aspirations and goals, and helping them accomplish and reach those goals, which means managing mental health systems. But the context is their desire for education or most likely employment. And a study that I have cited in everything I’ve written is one that a colleague of Marsha’s did some years ago at a youth center in Framingham, Massachusetts, which said that all the young people who came for help at this mental health agency came to find work. They wanted employment. That was their primary goal. And there was actually a SAMHSA, the federal mental health agency, Substance Abuse and Mental Health Services Administration, study that was reported at a national conference, which said the same thing. Young people come to mental health agencies looking for work, not for counseling or mental health service.

[00:09:47] Jon M: So you in that kind of setting and situation, what are some of the strategies that you can use that will go with the motivation and will provide, meet some of the needs that the young person may have who’s coming in, as you said, looking for a job, but you’re also seeing that there may be barriers that they need to work on.

[00:10:09] Marsha E: You know, so engaging youth with mental health condition and services is a very central topic. And the primary way to do that is first to meet the young person where they’re at. So that sounds like a very old social work term, but it lives today, and where the youth is at is that I want to get a part-time job, or I want to have friends and I don’t have any, or maybe it’s it’s I want to get along better with my family, or I want to figure out how to move out from my family. That that’s where you meet them and you start working on their goals with them. And in the course of doing so, things come up like, “Geez, I felt too anxious to go and meet that landlord,”or, “It came time for the test and I just couldn’t go to class that day,” or “I couldn’t get up” or something like that. And that provides an opportunity for the worker to start thinking, to start uncovering, with the person. Well, what is that all about? What, where did that come from and how could that be helped? So in that way, you know, more traditional mental health ways of thinking can be brought to the young person in a palatable way.

What we once heard from young people at a conference with them, “Don’t be a dream killer.” You know, if I, if I come in and I say, look, what I really want to be is a rap star. You don’t start with, you know, how impossible is that for you because you can’t even play an instrument, but rather sort of explore, well, what does that take? And, and given what that takes, what would be an appropriate first step? So you don’t kill the dream. You try to keep it possible and alive, or at least you explain it so that the individual can actually see what does that mean and then adjust accordingly. 

Some of that, we heard this from a provider for young adult mental health services. Well, maybe you are not fit to be a rap star, but maybe you want to be a music promoter, or maybe you want to be a sound engineer, or maybe what you want to do is work in merchandising and figure out how to sell bands’ material, and so forth. Anyway, those give you some clues for engaging students in services who might otherwise might show them. 

[00:12:36] Evelyn F: The trick is to engage with them. I mean, that is the key thing. It’s the relationship building. And one of the challenges, so before I mentioned, and I didn’t find the statistic, but I’ve written it up multiple times is, you know, the problem with Medicaid funded services is that they don’t cover it the intensity of what building that kind of relationship is about. Medicaid pays for clinic, half hour to come in. Did you take your medication? No. Here’s more medication. And so what’s needed is the labor intensive work of the relationship. And then the question of just getting to school, knowing that today you’re really not gonna have much possibility in life if you don’t finish high school.

I did a focus group, when I was still in Massachusetts, with a group of people who had just barely graduated from high school. And I asked each of them how they had, you know, what, who would help them? How did they get through high school? Invariably, it was a parent that was, most of them said, “My mother just made me get up in the morning and go to school. When I was upset, my mother made me do it.” You know, if they have to do something.

Alternately, it was some teacher who just had taken that young person on, and was the relationship. But they all had struggled to get through high school and none of them had a simple, straight forward trajectory.

And by the way, one other factor that gets in the way of successful trajectory is mobility. New York State said they couldn’t give me the information, but Massachusetts did give the information about if a student moves three or four times in their high school career, they have something like 35% chance of graduating. So mobility, and given that these young people may be in families who are housing insecure or may be in foster care and be changed in their placement. Just mobility in the high school years is a problem factor in finishing high school. 

[00:14:54] Marsha E: Yeah, I think it’s, it’s very important to recognize that many students with mental health conditions in high school are quote intersectional youth, and they have many other issues that are besetting them besides their mental health condition. And so, if it’s generational poverty, you know, going back, and if they are students of color and they’re facing systemic racism, all sorts of mental health conditions, and also, you know, opioid addictions and other kinds of issues that are going on in the family.

One of the tasks is not to just look narrowly at the mental health, and is to see the whole context of where the youth is coming from. 

[00:15:40] Jon M: What degree are college and career counselors in schools trained or in an environment where they can effectively support students with serious mental health issues in applying for post-secondary activities, whether it’s going to college or, or getting jobs?

[00:15:59] Marsha E: Yeah, I can’t speak to that precisely either in my, so, so in a, not in a research based experience, but in, in personal experience, I think that high school guidance counselors understand that students who are in special education really have a disconnect when they go to college in terms of getting the accommodations that they got in high school and will appropriately coach youth and families about how are you going to go get those accommodations in college, because it’s a completely different setup in high school. There’s some thinking that, you know, some youth in special education with mental health conditions are over-accommodated. By the time they get to college, it’s, it’s a shock. It doesn’t even make any allowances for you. You have to ask for your accommodations, you have to go to disability services, you have to provide the documentation, and you basically have to advocate for yourself that the professor gets those things, understands them, and accepts and goes along with them.

And of course, youth in college, similarly, don’t want to identify themselves as having a disability. So that’s a whole other kettle of fish, so to speak, is to work with youth who are entering college and to consider that this is an opportunity and you can get really helpful, needed supports, but at the same time, they have to understand that they have to identify themselves as having a disability and come to some degree of acceptance of that, which can be a stigmatizing label.

So that really doesn’t completely answer your question about high school transition counselors. I think that they are good on the accommodations. And I think that when it comes to really sort of figuring out how to deal with mental health conditions, their best bet is to refer the family to outside help. Sometimes there are school psychologists that are more knowledgeable, but they tend to be doing all of the testing and just coming up with, you know, whether the student has their IQ is, and whether they qualify for special education based on that. And it doesn’t provide the kind of personal intensive relationship that Evelyn was talking about.

[00:18:23] Evelyn F: Yeah. So if we think about what many of these personnel are committed to testing, and that is just a limit, you know, limitation. The problem for so much of this is the kind of intervention, the one-on-one [inaudible] school sometimes positive youth development, which is pretty much what its name says, but it’s intensive and one-to-one, and Medicaid doesn’t cover that. If you’re a person trying to get mental health services through Medicaid, it’s very clinical. It’s like going to get your foot examined. And so we were talking before we started this on the double edge of special education. And the plus and the minus and the complexity of it all, which is, it may be, it may not always be, but by and large, it is seen as a stigmatizing thing to do, to put a student in special ed. And certainly the effort around discipline has acted as if it’s a disciplinary action, to put a student in special ed rather than a positive action for their benefit. And at the same time, special ed could provide more resources than other forms of intervention, whether Medicaid or something else, to help a student.

So I want to just mention here that Marsha has been leading this effort at the UMass Center around three pieces to special ed reform that could benefit students placed in special ed for behavioral health, which is: at least four credits of continuing and technical education, a relationship with community-based agencies, the school and the community-based agency and the youth and family have a relationship, and a student-led IEP, Independent Educational Plan. So the formulation of what could work, to make a serious effort, is there. 

And what I am trying to do is find places that want to build from the bottom up, to take these concepts and learnings and say here’s how it can work in different school districts. Because to my mind, having been in the mental health field for decades, I won’t say how many, there just hasn’t been this kind of serious approach to making school, particularly high school, into a positive experience for a young person with a mental health challenge. 

[00:21:08] Marsha E: Yeah. Thank you, Evelyn. You’re referring to the Transition Evidence to Support Transitions.

[00:21:15] Evelyn F: I am. I am. I’m a fan.

[00:21:19] Marsha E: So we do have a website on TEST. That’s the acronym on the UMass Medical Center, Transitions to Adulthood Center for Research. Those three components of tests that Evelyn described are research-based. So this is not, you know, out of somebody’s thought about, hey, this would be a good thing. It was based on longitudinal data collected by the SRI Institute, following students who were in special education through and past high school through many years forward. And then they analyze what were the correlates of those students for those who were labeled with emotional behavioral disturbance and what was correlated with their positive employment outcomes, post high school. And those were three that came up. And they do correlate with other special education research. And that’s what was very gratifying. So yes, student-led IEP. 

So if you’re a special educator out there and you’re doing IEP, give your student a chance to actually understand what the heck this is why it’s valuable for them, what are their rights. And give them an opportunity to actually lead it to some extent, like describe what, what is their vision, what are the resources that they imagine that they need to fulfill their vision from the school system? And that’s a very empowering action that seems to have a real positive effect in the longterm. Who knew? But yes, so that’s a great one. 

And also the research found that, this was not research conducted by me, it was by Mary Wagner at SRI. So if you bring community partners into the IEP process, and by that we are speaking of community college representatives or vocational rehabilitation agency counselors. And it could be others, Department of Mental Health, housing, income support, and get those people connected to the student while they’re in high school so that there is actually a seamless transition as they leave high school and they move on to the community, into their post-secondary life. Again, there was like a four-fold increase in employment supports, in actual employment and wages earned for those students who had that kind of intervention in high school.

And the third one was career and technical education. So yeah, four credits in high school along a singular career pathway. So that means I’m not like, well, I take hairdressing one semester and I take automotive the next semester, and then maybe Microsoft Word or something like that. But credits along a career pathway, and these career pathways are very clearly defined in the U S Department of Labor and in state labor departments. Ideally, four credits in a career pathway that leads to a career that’s in an in demand industry, as it’s called for the state. Every state has its own set of in demand industries. And a lot of it has to do with STEM kinds of employment and STEM education. If you can put a student through four credits of that in high school, again, we see like a fourfold increase in employment after high school.

And those are the goals that we want to achieve. You know, we’re really not trying to achieve symptom remission, fewer hospitalizations, per se. We want these students to graduate high school and then to achieve a successful post-secondary life, either by more training and education or employment.

[00:25:09] Evelyn F: Right. And not to be on SSI alone, because SSI, if you don’t graduate high school, and if you don’t have some kind of decent place to work, you know, that pays a living wage, what your future is, is a life of poverty. On SSI, disability, on the margins of society, which is not good for citizenship or for employment or for mental health. And that’s why these young people come to agencies saying, I want a job. Job is such a definer in our society and that’s what people want. 

So the CTE thing, which has really fascinated me, and partly because there’s been a push of late back to apprenticeships. And so the vice president for cultural transformation, I think is his title, at IBM, located in Westchester, has been talking about not requiring college degrees for entry jobs. He’s promoting a kind of CTE apprenticeship approach, in which young people learn and come to IBM and other companies. And this is the kind of thing students with a serious mental health challenge could accomplish. The Biden administration has put forward apprenticeships as a policy goal, and some legislation has passed the House, but not the Senate. Maybe it will be in the big infrastructure bill, to expand youth apprenticeships, which have not been very much available for several decades for reasons I don’t know, but just the whole question of work-related pathways for young people with mental health challenges seems to be very therapeutic. 

[00:27:02] Jon M: So in addition to helping young people get on this pathway that you’re talking about, there are frequently high rates of suspensions of students in special ed. And often of course, there’s disproportionate suspension of Black young men and young women. What are some of the ways that schools can move from a punitive approach to a supportive approach for young people with serious mental health issues when behavioral issues arise?

[00:27:40] Evelyn F: Well, this is where I think, you know, the engagement strategy is so important, that the behavior… By being engaged with a young person, you’re trying to help that person not get to the point where they do the behavior that causes problems for them. They’re able to perhaps talk about it and say, “I really wanted to kick John in the head.” instead of doing it, they have said it in words and been able to figure out, “why am I so angry” and “how do I focus on what I’m supposed to be doing, which is my apprenticeship, which I really love, and I don’t want to be thrown out of school for disciplinary violations.” 

and this is where also, I think, some school districts have tried to put into place restorative justice practices. On a phone call recently, Ellen in Peekskill described a student who got into a fight with another student and was not going to be able to go to graduation. And he got really upset that he couldn’t go to graduation after really working hard. And they figured out a way to restorative justice, that the student could apologize for his actions to the other student and to school personnel and take responsibility for his behavior. And it made a difference. The student could graduate and walk across the stage.

And so, you know, this is why I’m so interested in the local, working in some kind of little fishbowl, where schools can combine these practices that they entered, practices like a focus on CTE or student-led IEP, with other practices that have been in schools, like restorative justice or SEL social emotional, and you put the whole thing together. And it’s labor intensive again to make this work for students and for a better school atmosphere, where a different kind of culture is created that enables the student to be successful rather than focused on his or her deficit of a mental health problem. 

[00:29:55] Jon M: Shifting a bit, the Transitions to Adulthood Center for Research emphasizes participatory action research with young people with serious mental illness. What does that look like? And do you find that the action research process itself has positive effects on mental health? Marsha? 

[00:30:13] Marsha E: Yeah. I mean, there is some research about that, so I’m going far afield right now, but, you know, generally speaking, peer support. And for people who are engaged in peer support as adults or youth, it does have a positive effect on the peer supporters themselves. You know, giving to others helps one feel better.

But in any case, as far as participatory action research, yes. I mean, as an old time researcher, when you bring in the voice of the people for whom you’re actually trying to do something for, you learn things that you just don’t otherwise learn. And that’s just, it’s a very simple principle, the end user of whatever it is that you are doing, and this goes for, you know, car makers and shoe designers. Speaking of going for a foot exam, you know, if you are working with your customer base and really sort of understanding what their needs are and they are working with you. 

And what we are really about these days is what we are calling coproduction. And so all of our efforts, whether they are research or they are developing a video or they’re figuring out a good administrative process. From the entire organizational enterprise, if the end user is involved in a meaningful way, and I stress meaningful, because it’s very easy to have the token person who comes in, or there’s an advisory board to whom you present something and they give their opinions and then the rest of the organization goes and does whatever it is they were going to do to begin with. So there’s sadly plenty of that, but if there actually is a way to develop a process of meaningful participation, then the product is better. And the result is that it’s more relevant, more meaningful, and better used and has better outcomes for whomever the audience is that it’s intended for.

[00:32:22] Jon M: Psychiatry has a very mixed ethical history with regard to people of color women and LGBTQ+ people. Especially in the light of the reexaminations that have been taking place after George Floyd’s murder and the Black Lives Matter demonstrations, what kinds of self-examination are taking place in the field?

[00:32:44] Evelyn F: I’m not a psychiatrist, I’m a social worker, so I can’t speak for psychiatry. The only thing I will say is I listened into a, I guess it was the Zoom meeting, I think it was NAMI in New York City, and they had a Black psychologist. I think he was a PhD psychologist who spoke to this issue of the ways in which mental health had used terms to describe people, which he felt were quite racist. I was a listener and I didn’t take notes, but I was intrigued by his analysis.

[00:33:22] Marsha E: Yeah. I’m not a psychiatrist either. 

[00:33:26] Jon M: I’ll be happy to extend the question generally. 

[00:33:29] Evelyn F: To social work. 

[00:33:33] Marsha E: I think that there is some sincere efforts by organizations to do some self-reflection. So I can speak for my organization at UMass Medical School, taking deliberate action to actually hire people of color and provide a mentorship structure so that people of color will feel supported. And also, importantly, to develop a pipeline so that young people can come in as, you know, research assistants and research coordinators and have the support to move up both professionally and academically. And I think psychiatry is doing that too, but psychiatry does have a lot of history to live down and, you know, right now psychiatry is still the epitome of the medical model.

So, you know, there are of course wonderful psychiatrists out there that are trying to reform the field. But I think that the rest of them are really beset by massive caseloads, restrictive insurance policies, where their role is narrowed into a 15 minute medication review. And you write a script and you do the best you can. And I think psychiatrists are not that happy, you know, and they would like to form relationships with their patients. But I mean, it’s a very large structural issue that goes beyond the individual person.

[00:35:08] Jon M: Thank you, Dr. Marsha Ellison, of Transitions to Adulthood Center for Research. And Evelyn Frankford of Frankford Consulting. 

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